J Stroke.  2023 Sep;25(3):338-349. 10.5853/jos.2023.01599.

Cerebrovascular Events in Older Patients With Patent Foramen Ovale: Current Status and Future Perspectives

• Farjat-Pasos JI
• Chamorro A
• Lanthier S
• Robichaud M
• Mengi S
• Houde C
• Rodés-Cabau J

• KMID: 2546435
• DOI: http://doi.org/10.5853/jos.2023.01599

Abstract

Patent foramen ovale (PFO) closure, along with medical therapy, has emerged as the therapeutic gold standard in younger (<60-year-old) patients with a PFO-related stroke for preventing recurrent events. However, PFO management guidelines lack definite recommendations for older (>60 years) patients with a PFO-related cerebrovascular event, a complex group of patients who were mostly excluded from PFO closure clinical trials. Nevertheless, several studies have shown a higher prevalence of PFO among older patients with cryptogenic stroke, and its presence has been associated with an increased risk of recurrent events. Furthermore, older patients exhibit a higher prevalence of high-risk PFO anatomical features, present inherent age-related risk factors that might increase the risk of paradoxical embolism through a PFO, and have a higher incidence of ischemic events after a PFO-related event. Additionally, observational studies have shown the safety and preliminary efficacy of PFO closure in older PFO-related stroke patients. Yet, higher rates of recurrent cerebrovascular events and new-onset atrial fibrillation were observed in some studies among older patients compared to their younger counterparts. After careful case-by-case evaluation, including the assessment of hidden potential cardioembolic sources of a cryptogenic stroke other than PFO, transcatheter PFO closure might be a safe and effective therapeutic option for preventing recurrent thromboembolic events in patients >60 years with a high-risk PFO-associated stroke. Ongoing trials will provide important insights into the role of PFO closure in the elderly population.

Keyword

Patent foramen ovale; Cryptogenic stroke; Elderly population

Figure

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  Figure 1. Patent foramen ovale (PFO)-associated stroke in the elderly population. The main clinical manifestations are stroke, transient ischemic attack (TIA), or peripheral embolism. This can be caused by two mechanisms: paradoxical embolism or in situ thrombus formation. The main high-risk anatomical PFO features are (A) long tunnel (dashed yellow line), (B) large PFO, >2–3 mm (yellow square bracket; yellow arrow depicting a large free passage of bubbles from the right atrium to the left atrium), and (C) atrial septal aneurysm (yellow asterisks). A heart-brain team should carefully evaluate case-by-case to assess the potential causal association between a non-lacunar stroke without any definitive plausible cause in the presence of a high-risk PFO to consider transcatheter PFO closure, ideally after discarding occult atrial fibrillation (AF) with a reasonable approach, perhaps requiring a long-term monitoring system.

Reference

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